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After reading Richard Quinn’s recent post about Medicare, I thought this would be a good place to solicit thoughts.
I have a 64 year old brother who is single, has no other immediate family, and is currently on Medicare disability due to mobility issues. He has a medicare advantage plan which has coverage for his prescriptions (Part D), vision and dental. As he is now within 3 months of his 65th birthday, he has the opportunity to switch to original medicare without underwriting, which he would fail (this window expires at the end of February). The out of pocket cost with a Medigap policy and Part D (not even considering vision or dental) would be considerably higher than he is currently paying, as he pays only the cost of the Part B premium now.
My brother’s financial position is precarious to say the least and he does not have the means to pay more for health insurance. The expected cost increases in 2026 alone are going to be a significant financial burden. Additionally, his disability social security benefits, while insufficient for daily living, are slightly too high for him to be eligible for medicaid or any other assistance in the state where he lives.
I am concerned that while his Advantage plan is considerably less money than original Medicare on the front end, the cost of co-payments, deductible, etc. will also be too much for him and serve as a disincentive to receive care that he might need (I have seen this already to some extent). His doctor choice is also much more limited, although his current doctors accept his insurance.
I have considered offering to pay for a Medigap policy (likely Plan G) and a Part D Plan for him so that he can convert to original medicare and continue to only be responsible for his standard Part B premium. My concern is that this will be an ongoing expense and I have no idea how that expense will rise over time. Of course, I also have my own medical costs to consider as well as my wife’s, not to mention retirement costs in general.
I am soliciting suggestions and views from those of you who have experience with this (I am a few years away from Medicare age myself). Is Medicare Advantage good enough?
I realize that many people live happily on Medicare Advantage plans, but I also have heard that those who have substantial medical issues tend to prefer original Medicare with a gap policy and Part D. I also know that changes to Advantage policy pricing and benefits are likely to be coming.
Thank you in advance for your thoughts.
Tough decision. He may not qualify using underwriting in the future or it could be very expensive. A few thoughts based on our situation and my experience as a Medicare SHIP volunteer. We moved from a large urban area where we had a high quality large network MA plan (Kaiser) to a small rural state with national plans but small MA networks and no 5 star plans. Yes, we know Kaiser isn’t perfect, but it towers above most plans. We chose to switch to straight medicare and supplement since moving allowed us choice without underwriting. We have been happy with the switch -everything paid for. There’s benefit to having a fixed cost without coinsurance, no preapprovals, etc. and, so far, no limit on providers. If I was in your situation, I’d look carefully at his policy for quality rating, his cost liability and extent of network. Read through complaints on the medicare website. If he cannot afford the supplement his copays and coinsurance could be devastating financially. If I was a helping financially and the plan was average, I would talk to a SHIP volunteer about better MA plans but probably buy the supplement for a more even cost. If the plan appears to be excellent, I’d put aside money to help with coinsurance etc. Finally, as a SHIP volunteer in the rural state, I had many people prefer nearly free MA plans when they were healthy only to return for a change to a supplement when their health declined and costs increased. They were usually surprised and very angry they now faced underwriting . His plan today probably is cheaper, but that could change tomorrow. Good luck. You’re a good brother.
Isn’t it the case that you can’t be refused for a Medicare Advantage plan? So he could switch back if necessary, while this is a likely one time opportunity to take Medicare plus Medigap.
Yes, exactly. The only real issue, I guess, is that he can’t afford it, so it won’t happen unless I make up the difference between what he would pay for his MA plan and what Original Medicare plus Medigap and Part D would cost. And once he is on Original Medicare, I suspect he won’t want to switch back. So essentially if I go that route and offer to help him out, it is likely going to be a lifelong financial commitment. On the other hand, I would like to make sure he has access to the care he might need. If he can get that through Medicare Advantage, that’s great. Unfortunately, it’s not really possible to know whether what works for him today will continue to work. And if it doesn’t, as you say, he likely won’t have that opportunity again.
I was looking into that idea. As per the folks at Medicare.gov you can switch between Trad. Medicare & MA programs during the open enrollment period. The problem is with Medigap/Supplemental Plans. I’m subject to underwriting and I have a condition (psoriatic arthritis) which enables those plans to deny me coverage.
I am a retired NJ State employee. I have Aetna MA Extended Service Area (nationwide coverage). Started this plan in December, 2020. In retrospect, I should have enrolled in Traditional Medicare. However, I will say this plan has been very good. Zero deductible and $15.00 copays for PCP/Specialists. $1000 Out of Pocket max per year. The network in Northern NJ is extensive. Even if a Dr. is not In Network you can use him/her as long as they accept Medicare. I pay the Medicare Part B premium and no other premiums. My concern is the long term viability of MA plans.
The key to your coverage is you are a NJ state retiree. The benefits and premium are designed for that group and subsidized by the state most likely.
Other important consideration is preapprovals and doctor/hospital network. I also have health challenges and am eligible for Medicare. Although more expensive than MA …. my cost is roughly $185/month for Part B + $322/month for supplemental/gap + $0 for Part D/drugs.
I do not need to deal with the preapproval process thru MA and have extensive network of doctors, this is worth the extra cost. Another factor is the total deductible which is about $250/year.
The Part B will increase over time. It’s important to ensure you choose an insurance company who has a good track record in the state where he lives.
Leave him on the MA plan unless he hates it for some reason.
I would be interested to hear your rationale. He honestly hasn’t said anything particularly negative about his plan except that the copays and coinsurance are expensive. In actuality, I suspect what he has spent to date this year is less than he would have had to pay for a gap policy.
Just the financials. Cheaper for him on MA now.
I agree. We both are on a MA Plan. We have no problems and no concerns. We are glad we made the choice we did
There is a growing issue to keep an eye on regarding stability of MA plans.
“In 2025, payments to MA are 20% more per person, which translates into an additional $84 billion in federal spending this year, substantially larger than the $18 billion in higher spending a decade ago when about one-third of eligible beneficiaries were enrolled in a Medicare Advantage plan.
Given the enrollment and spending trends, policymakers have become increasingly focused on how Medicare pays private plans, though without broad agreement on how or when to move forward.
In part, the difficulty stems from concerns about the effects of payment changes for beneficiaries’ choice among plans and access to supplemental benefits, such as coverage of dental, vision and hearing.”
“Given the enrollment and spending trends, policymakers have become increasingly focused on how Medicare pays private plans, though without broad agreement on how or when to move forward.”
Not likely due to the political bribes, oops, I mean donations to congress from the insurance companies.
“In 2025, payments to MA are 20% more per person, which translates into an additional $84 billion in federal spending this year, substantially.”
And yet there is an outcry over Federal “waste, fraud and abuse”
And get this there is talk about the government forcing everyone onto MA in the future!
Please be aware that if he wants part B coverage he also would have to pay the Federal Part B premiums (which cover medically necessary and preventive services, including doctor visits, outpatient care, ambulance services, durable medical equipment, and various screenings and tests) which at this point is tentatively projected to be $206.50/month or a $21.50 per month increase. Right now we in NH pay $157 per month for our plan G, but nothing for our part D (medications).
Thanks. Yes, he is currently paying $185 for the MA plan.
In NH my wife and I are paying $160 per person for plan G ie no copays or deductible other than the Federal of $257 this year.
There are two primary considerations. What are the deductibles and co-pays/insurance in the MA plan and does the network of providers meet his needs now and likely in the future?
A Medigap policy could eliminate all medical out of pocket costs, except perhaps the deductible unless he is eligible for plan F
It’s a good bet all premiums in all options are going up each year. IMO right now the risk for increases is greater for MA plans.
You can see the projected Part B and D premium increases by looking at the trustees report page 202
Thank you. The question about whether the network of providers likely will meet his needs in the future is a difficult one to answer. One never knows if even his current doctors will continue to accept his plan. What original Medicare would provide is a greater degree of certainty as to costs, albeit likely higher costs in some years. I believe his OOP limit currently $3500.
Original would also guarantee open access to care. If he is paying $185 that is standard Part B premium so if he goes with a Medigap, that will be additional, on the other hand no OOP costs except perhaps Part B deductible.
have you checked Plan G prices for example and to compare with his OOP costs now annually. And don’t forget Part D prices.
Only on the Medicare.gov website. Are these prices usually generally close to accurate (at least for initial comparison purposes) or is it really necessary to contact each company directly? Part G Plans in his area are $135-$569 per month. They have attained age, community pricing and one issue age plan. I thought since he is just turning 65 maybe the issue age plan might make sense and save money over the long term. I haven’t really been able to compare Part D plans yet as I need a list of his medications to accurately compare. There are a lot of moving parts.
I would always check with the plan for pricing. We have attained age and I wish we had issue age. Work on that Part D because that could be your greatest OOP risk.
try a site called VIA benefits. I think they let you model Part D plans, but you need the Rx names to do it right and get your potential total OOP costs a year.